While it?s still too early to say that the ACR?s Appropriateness Criteria can decrease the growth rate in imaging utilization, the ACR is doing its best to spread the word.

The American College of Radiology?s Appropriateness Criteria (AC) were created in 1992, yet it has been only in the last 5 years that physicians and health care stake holders have begun to find more ways to incorporate them into technology and quality measures. Today, referring physicians can find the AC incorporated into preauthorizations from radiology benefit management (RBM) companies, licensed decision support software, and, most recently, a new application for mobile phones. And yet, much work remains to not only continue to update the AC, but also encourage referring physicians to use them.

RadPort from Nuance is a physician order entry system and decision support software that uses the AC with the referring physician?s imaging ordering process.

Getting the Word Out

The AC is not a panacea for decreasing the growth rate of imaging utilization, but it?s certainly an evidence-based respected standard that can be utilized by physicians, health care informatics, insurance companies, and RBMs.

The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) provides funding for a pilot to evaluate the AC in the medical imaging decision-making process and their effect on the quality and cost of imaging. However, that pilot has just been launched.

In the meantime, the College continues to reach out to referring physicians for its AC expert research panels and for AC distribution. Since introducing the AC in 1992, the ACR has intermittently updated its guidelines, incorporating research from 20 other medical societies. The content contains more than 160 individual topics with 800 variants, with a vast volume of evidence-based literature.

James H. Thrall, MD, FACR, Board of Chancellors chair at the ACR, as well as a practicing radiologist at Boston?s Massachusetts General Hospital (MGH) and a Harvard professor, said that the ACR used to have a difficult time attracting other specialties to participate in its expert panels. Recently, however, that reluctance has changed.

?Now, every specialty out there is coming to the College and demanding to be allowed a higher level of participation,? said Thrall. ?Because everyone realizes that there?s an expectation from the insurance industry and CMS that methods be put in place that are objective and evidence-based and that allow decisions to be made around utilization.?

David Kurth, director of Practice Guidelines, Technical Standards, and Appropriateness Criteria at the ACR, added that ACR?s goal is to empower physicians to use the AC as a supplement to referring physicians? radiology knowledge base, which is why the ACR is trying to make it easier for the physicians to use the AC at the point of care.

?The fact is that ordering physicians are medical doctors who have great knowledge and a lot of experience,? said Kurth. ?I think for them to get used to incorporating the AC into their workflow is a challenge.?

AC Decision Support and RBMs

To make the AC as accessible as possible for referring physicians, the College has published and licensed its content to RBMs, insurance providers, and order entry and decision support software.

One test of the AC effectiveness in decision support software occurred at MGH, where referring physicians have been using Burlington, Mass-based Nuance Communications? RadPort product. RadPort is a computer-based physician order entry system and decision support software that use the AC with the referring physician?s imaging ordering process.

Unlike RBMs, with RadPort, the final imaging exam decision is left up to the referring physician. Exams being ordered receive an AC-based score of 1 to 9, with 9 being most appropriate. Physicians are allowed to order a 1 exam, but must document their reasoning, which is later reviewed by peers.

A 7-year MGH study published in 2009 using RadPort at MGH showed a dramatic decrease in the growth rate of some imaging exams, particularly in CT and ultrasound. Specifically, on a yearly basis, the growth rates before and after implementation of the RadPort system were as follows:

  • CT: 12% before implementation, 1% after
  • MR: 12% before implementation, 7% after
  • US: 9% before implementation, 4% after1

James H. Thrall, MD, FACR

Thrall reported to Axis Imaging News that follow-up data since the 2009 study has shown an even steeper decline in MGH?s utilization rates. However, Thrall also noted that the sharp decrease in imaging demand is likely not attributable to the utilization management system alone. Rather, he suspects that the recession was a significant factor.

The other way that the AC is being incorporated is through the RBM system. While RBMs are certainly part of the physician?s workflow, there is some question as to whether they provide enough flexibility for referring physicians. Unlike an AC-based decision support software that advises physicians on a scale of 1 to 9, with 9 being the most appropriate exam, RBMs tend to be more definitive with a simple yes ? or no.

?I would argue that medicine is not practiced as a binary exercise, but with shades of gray,? said Thrall. ?RBMs don?t take into account the wisdom of the ordering physician?the special knowledge that that person has about the patient.?

Thrall elaborated, explaining that doctors often come upon situations where they just have a certain feeling about the patient. These intuitive moments may be derived from the timbre of the patient?s voice, or a tremulousness, or a look on the face.

?The words might be the same from one patient to another, but the way the patient looks, the way they?re responding, you cannot reduce that to a few sentences in a telephone conversation with [an RBM representative] thousands of miles away,? said Thrall.

New Mobile Application

The ACR feels strongly that the AC should be accessible at the point of care?and not just in front of a laptop or an office workstation.

?The appropriateness criteria will remain of only theoretical value until they can be delivered at the point of care. That requires contemporary information technology solutions,? said Thrall.

To help give physicians more access to the AC at the point of care, the ACR has developed a new mobile phone application for the iPhone, Blackberry, Android, and other platforms.

The ACR?s ?Anytime, Anywhere? application is designed to give ordering physicians and radiology oncologists real-time access to appropriateness criteria.

The ?Anytime, Anywhere?” application from Skyscape, Marlborough, Mass, is available to referring physicians for $55.95/year or $126.95 for 3 years. ACR members receive a discount through the ACR?s Web site at acpda-auth.acr.org.

Kurth said the application is intended to provide ordering physicians as well as radiology oncologists with immediate, real-time access to the AC.

?We know that in some places, it?s difficult to get to your computer screen, or you?re out on the run, and we realized that people had hopes for a more portable version of the appropriateness criteria,? said Kurth.

The interface is somewhat different for each handheld device. However, in general, the program is divided into different topics.

For example, if a patient had a gastrointestinal concern, a physician would navigate to that panel, and drill down further with more specific choices, such as right lower quadrant pain. The appropriateness rating table will eventually appear and indicate a 1 to 9 appropriateness rating for specific procedures being considered, plus suggested variants, as well as a relevant radiation level for each procedure. Other tabs lead to a related literature summary and the date of the last review of the literature.

Reducing Inappropriate Exams

The ACR is well aware that dissemination of the AC through mobile phones, order entry systems, and RBMs are just one way to help reduce inappropriate radiology exams.

Other solutions include the stricter accreditation standards for both outpatient and hospital-based advanced imaging facilities. More recently, decreasing inappropriate self-referral has become a topic of discussion in Congress ? again.

At the end of April 2010, at the request of the American College of Radiology, a Congressional committee has asked the nonpartisan General Accountability Office (GAO) to study how physician self-referral affects Medicare spending.

Imaging costs and self-referral have been studied in the past. The GAO2 and the Journal of the American Medical Association3 have both reported evidence that radiology utilization is significantly increased when physicians have a financial interest in a referred imaging facility.

As a result of past ?Stark Laws,? named after their sponsor and anti-self-referral champion, Congressman Peter Stark (D-Calif), physician self-referral has been substantially reduced. Currently, it is illegal for a physician to refer a patient to his own medical facility or service?with one exception, known as the ?in-office exception.?

Under the in-office exception, if a physician owns the facility in the same building or hospital campus, they can legally refer patients to that facility. The exception was intended as a convenience for the patient and to enable faster care and diagnosis.

However, in-office referrals have proliferated through leasing structures. In these time-share arrangements, instead of owning a radiology center in the same building, a physician simply leases a time slot at the building?s imaging facility. The referring physician can then generate self-referral revenue when patients visit the imaging facility during that specific time slot.

Whether this leasing arrangement leads to unnecessary imaging exams is unclear, and that is why the ACR requested Congressional leaders to ask the GAO to study the issue.

The Future

While there is certainly a trend of wider adoption of the AC, Thrall cautions that more time and technology are needed before they become more commonly used.

Thrall said, ?It was only about 5 years ago that people woke up to the concept of appropriateness criteria. So, it?s going to take another 6 or 8 years for them to be widely promulgated, for the technology to be developed, for the information platforms to be developed, and to deliver them at the point of care in a way that?s convenient to the work processes of physicians.?

While CMS has not adopted the AC into ordering Medicare tests, the results of the aforementioned MIPPA pilot program may move CMS?and all physicians?toward significantly greater AC adoption.

Tor Valenza is an associate editor of Axis Imaging News.


  1. Sistrom CL, Dang PA, Weilburg JB, Dreyer KJ, Rosenthal DI, Thrall JH. Effect of computerized order entry with integrated decision support on the growth outpatient procedure volumes: seven-year time series analysis. Radiology. 2009;251:147-155.
  2. www.qualityimaging.org/analysis/GAOHEHS.pdf
  3. Hillman BJ, Olson GT, Griffith PE, et al. Physicians? utilization and charges for outpatient diagnostic imaging in a Medicare population. JAMA. 1992;268:2050-4.